Joanna Grudziak, MD

PGY4
General Surgery
Yaw, roll, and pitch

Rudder, aileron, elevator

Takeoff, flight, landing

https://en.wikipedia.org/wiki/Aircraft_principal_axes
Central Line placement associated with potential major morbidity:

 Infection
 Arterial injury
 Hemo- and pneumothorax
 Stroke
 Cardiac tamponade

https://openi.nlm.nih.gov/detailedresult.php?img=PMC346876
7_jkms-27-1265-g001&req=4
 Central line complications related to placement decrease with:
 Clinicians who have performed > 50 line insertions 1

 Fewer attempts (<3 needle sticks) 1

 Ultrasound use 2

 Simulation-based training for clinicians 3

Previously no standardized teaching method for UNC residents

1. Young MP. (2016). Complications of central venous catheters and their prevention. In: UpToDate, Collins KA (Ed), UpToDate, Waltham, MA. (Accessed on May 17, 2016.)
2. McGee DC & Gould MK. (2003). Preventing complications of central venous catheterization. NEJM, 348: 1123-1133.
3. Barsuk JH, McGaghie WC, Cohen ER, O’Leary KJ, & Wayne DB. (2009). Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care
unit. Crit Care Med, 37(10): 2697-701.
 Inaugural Multidisciplinary M&M – June 2014
Resident-led
Central line complication resulting in vascular surgery intervention

 Resident Task Force formed with assistance from faculty across five
departments:
Anesthesia
Emergency Medicine Why?
Family Medicine
Internal Medicine
Surgery
To develop and implement a

standardized central line placement

training for all interns with opportunity

to insert central lines

 Intern Central Line Training Course
Introduction and Divide group into
pretest 3 learning stations

Line placement on
simulator demonstration

Central Line kits

(triple/double lumens) and Ultrasound Basics
sterility basics

Final Station: Groups of 3 learners perform Post test

Questions
and survey,
Central Line placement on task trainer feedback and closing
Teaching interns how to use
ultrasound to determine site
for central line placement

http://www.ultrasonix.com/blog/internal-jugular-vein-vascular-access-line-placement
CLeAR lab designed and built
custom-made simulator
 perfused, ultrasound-
compatible neck model
 pressurized liquid mimics
arterial/venous pressures
 capable of multiple sticks
without wear and tear
 very affordable compared
to market alternatives ($5K
for 3 vs $6K for 1)
Interns Trained
 99 interns in 11 classes
 Anesthesia – 12
 Emergency Medicine – 10
 Family Medicine – 10
 Internal Medicine – 35
 Surgery – 29
 Also, 3 from Neuro

Instructors Trained/Scheduled
 12 instructors in 4 “Train the Trainer” classes
Mean: 13.7 Mean: 16.1
95% CI: 13.1-14.3 95% CI: 15.7-16.6
median: 14 median: 16.5
p<0.001
Comfort increased for
line placement with
ultrasound, from 2.29 +/-
1.18 to 3.61 +/-0.79,
p<0.001

Comfort increased for

ultrasound basics,
from 2.70 +/- 1.13 to
4.10 +/- 0.6, p<0.001
 Thank you very much – this was a great experience!

 This was very helpful – I feel better prepared and more

knowledgeable.

 Thank you for taking the time to go over this

early in our training.

 This was a great training. Maybe we could do this twice

during our intern year.

 This was an excellent course. Even though I’ve had

some experience with lines before, I found this very
helpful.[I liked] getting to handle the line kit and get
more ultrasound experience.
 GME to take over
administration of central
line course for 2016-17
and beyond
 Data collection continuing
 Outstanding issues:
 protected time for faculty
 simulation home
 budget for supplies beyond
coming year
 resources for continued
data collection

 Central Line Video

 Filmed this spring
 Will be used for future
classes
 Multidisciplinary M&M
 UNC, Sept. 2015
 International Meeting for Simulation &
Health Care
 San Diego, Jan. 2016

 House Staff Council Meeting

 UNC, Feb. 2016

 Southeastern Surgical Congress

 Atlanta, Feb. 2016

 American Surgeon (publication pending)

 NC American College of Physicians meeting
 Greensboro, Feb. 2016

 Surgery Grand Rounds

 UNC, Jun. 2016
 “Nobody argues with a flight simulator”
-Tina Willis, MD

 Power of and challenges in interdisciplinary collaboration

 Learning from mistakes

 Original simulators
 Teaching suturing

 The blood, sweat, and tears of data collection

 Structural support essential

 Importance of residents driving improvement

 Persistence key to sustainability


guided central line training at UNC Healthcare.
1. Before routine insertion of a central venous catheter
all of the following steps must be done EXCEPT?
Obtain consent from the patient or their family or
guardian etc.
Perform a site survey with the ultrasound to ensure
the vessel is present and patent.
Cleanse the skin with chlorhexidine (if the patient is
not allergic) and allow to dry.
Use maximal barrier precautions, including hat, mask,
gloves, sterile gown and sterile full body drape.
Call your attorney.
2. Ultrasound guidance decreases mechanical AND
infectious complications of central line infection.
True
False
3. The best probe for vascular access guidance is
A HIGH frequency probe a with a FLAT footprint
A LOW frequency probe a with a FLAT footprint
A HIGH frequency probe a with a CURVED footprint
A LOW frequency probe a with a CURVED footprint
A phased array probe
4. Which of the statements below is CORRECT
regarding ultrasound guided vascular access?
(single best answer)
Using ultrasound only to identify landmarks without
visualizing needle entry is just as safe and effective as
using ultrasound throughout needle entry
Ultrasound decreases the complication rate with
central venous access.
A written note is sufficient documentation of
ultrasound guided vascular access, no images need to be
saved or printed for billing or QA purposes
It is unnecessary to put sterile gel inside and outside
the probe cover sleeve for ultrasound guided venous
access
5. Antiseptic disk (BioPatch) at the skin puncture site
is required for central lines at UNC.
True
False
Special thanks to the UC San Diego School of Medicine SICU Central Line Course for some of our test questions
6. This image of a central venous access procedure
shows:
The jugular vein is about 2.2 cm deep according to
the depth scale
The needle has penetrated the carotid artery
An "in-plane" or "along-the-needle view"
A non-compressible internal jugular vein due to
intraluminal clot
7. Which of the following are possible complications
of a central line insertion?
Pneumothorax.
Wire or catheter embolization.
Stroke (cerebrovascular accident).
Air embolism.
Arrhythmia including ventricular tachycardia or
fibrillation.
All of the above.
8. Ultrasound guidance for central venous line
insertion has been shown to do all of the following
EXCEPT?
Reduces infectious risk
Reduces number of attempts to successfully place
catheter
Reduces time required for inserting the central line
Reduces number of assistants needed for the
procedure
guided central line training at UNC Healthcare.
9. Betadine is preferred over chlorhexidine for skin
antisepsis: 15. This arrow in image below is showing: (single best
answer)
True
False
10. When advancing the catheter into the vein with
the Seldinger wire, it is critical that the catheter is slid
over the wire, and the wire and catheter are not
advanced together
True
False
11. Blood return into the syringe can occur while the Needle seen in the internal jugular vein in an “in-
needle is being withdrawn instead of being advanced. plane” approach
Needle seen in the internal jugular vein in an “out of
True plane” approach
False Needle seen in the carotid artery in an “in-plane”
approach
12. Medicare and many insurers will not pay for for Needle seen in the carotid artery in an “out of plane”
infections and pneumothoraces associated with approach
central venous catheter placement (CLABSI).
16. The correct way to sterilize skin with chlorhexidine is
to (single answer)
True
False
Use a scrubbing motion for at least 30 seconds
Cleanse the skin in a concentric circular pattern
13. After applying the chlorhexidine to the insertion Use at least 2 swabs/sticks
site, one should wait until the site is completely dry
17. Use of a checklist to adhere to infection-control
without fanning or blotting before proceeding.
practices as part of a central line bundle has decreased
True CLABSI rates in prospective trials.
False
True
14. Regarding central line insertions: (single correct False
answer)
18. The following practices help ensure that the carotid
artery (CA) is not injured during central line placement:
Pneumothorax is not a hazard of the internal jugular
approach. (single answer)
The internal jugular vein is accessible by a needle
inserted at the level of C6 aimed towards the contralateral Choosing a site in which the CA is just deep to the
nipple. internal jugular vein.
A chest X-ray is unnecessary to confirm central line Using manometry to estimate the pressure in the
vessel before dilating.
placement if the ultrasound documents the line inside the
vein. Viewing the guidewire in the vessel in the short axis,
out-of-plane view before dilating
When using 2D mode with the ultrasound, the lumen
of vessels should appear dark.